We are training physicians with an eye towards the past

How do you ask a person to be the last person to go through an education system that is failing them? Yet we’re doing just that. Every day tens of thousands of medical student wake up to an education, and an education system, that is failing them. This is not to say that we are not producing good doctors. On the contrary, our doctors are likely the most well-educated, and knowledgeable in history; but this is part of the problem. Every year the amount of information medical students are required to know increases. We do not replace information with better, more relevant information, we simply add more. But is increasing the flow from the firehose from which medical students are supposed to drink producing better doctors?

For decades we defined physicians by the amount of knowledge they accumulated, knowledge that separated the physician from lay persons. This knowledge was gleaned from years of study and kept in intimidating textbooks allowing the physician to enjoy a large knowledge advantage over his or her patients. This is simply not true anymore, and the sooner we as a profession and industry recognize it, the faster we can adjust.

The more I reflect on this, the more I think that medical schools produce the used car salesmen of a decade ago. Anyone who remembers buying a car ten years ago can remember being at the mercy of the dealership. You would walk in to the dealership with little knowledge of anything on the lot — what cars had been in wrecks, or the prices the dealer paid. Today, the playing field is level. Consumers are able to research and comparison shop before ever walking into the dealership. Today, physicians share the same advantages of the pre-Internet car salesmen. Physicians are the gatekeepers of information, but this role is quickly becoming outdated. Now information is just a Google search or a WebMD “diagnosis” away.

It’s easy to dismiss information individuals glean from Google, WebMD, or Wikipedia, although a survey by IMS Health found that 50% of Internet-using physicians consult Wikipedia for disease-related information. But even if these information sources are not currently up to the standards to which we hold practicing physicians, we are quickly approaching a point where intelligent computing systems will be able to provide far more sophisticated results. Even the best, most dedicated physician cannot stay up to date with all of the latest advances in medicine the way IBM’s Watson has been built to do. Yes, Watson is currently designed to aid physicians in diagnosis, but these kinds of technological advances will eventually find their way directly to the public, and then the knowledge advantage that physicians enjoy will mostly disappear.

So why are we training physicians with an eye towards the past instead of the future? Why are we training physicians to be the outdated used car salesmen of tomorrow? Physicians, and future physicians, should recognize that we will soon no longer be arbiters of information. Instead we will become interpreters of information for patients who show up for appointments already informed (or misinformed). This change in emphasis in physician training needs to begin with medical school. The goal of basic science education should shift from cramming minutiae into students’ minds to instilling mechanistic understanding of disease. The goal of medical school should change from trying to be the algorithmic computer to making, interpreting, and understanding these algorithms.

We can already see hints of these shifts in the inclusion of more literature interpretation, patient safety, and biostatistics in Step I and Step II, but we have not seen the same shift in medical education. The mentality of the status quo will not suffice for the next generation of physicians. After all, patients are already doing their part, coming to see their physicians with Internet printouts, 23andMe results, etc. Now it’s time for physicians and medical students to do ours.

We are training physicians with an eye towards the past 10 comments

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Suzi Q 38

As we would say in Hawaii: “Right on,” doctor.

Dr. Drake Ramoray

Agree with you Dike. I saw a patient last month who had correctly diagnosed himself with MODY Type 3. And that basic science that is minimized by the author is key to the appropriate treatment of the patient. The patient was key in his own health, highly knowledgeable. It was an awesome patient encounter. If nothing else, I have to be more on my basic science game, not less.

I have also had plenty of google search patient encounters. I prefer these types of patients invested in their own patient care (even if it’s misguided) to the 2 pack per day smoker, s/p CABG with redo, who comes his diabetes consult with powdered sugar on his face and a Dunkin Donuts large vanilla latte (true story). Embrace the e-patient it’s part of the fun these days.

Dave

I may have to be the dissenting voice here, though I agree with much of what you’re saying. While many patients are becoming more informed and taking charge of their healthcare, many either choose not to or don’t have the capability.

As a medical student, you’ve no doubt experienced the classic scenario where you gather a history from a patient only to watch the attending ask the same questions you did and get completely different answers. While I can’t wait to have IBM’s Watson on my tablet, I’m skeptical of its ability to intuit its way through when patients are being honest and thorough. It’s too often that patients will omit things either out of embarrassment or, more commonly perhaps, because they don’t believe it’s relevant to the problem at hand. You are right though, memorizing vast reams of information will be about as useful as being able to do long division in your head: a neat trick easily matched by any idiot with a calculator.

Finally, I think exactly the opposite solution may be in order: more basic science study instead of less. New drugs and treatments coming out and in the pipeline are getting more complex and harnessing elements of genetics and cell biology that would have been unthinkable 20 years ago. It’s likely that tomorrow’s physician will be required to think even more deeply about these things than we are now. If you’ve watched some of Watson’s demos, you’ve seen that its recommendations are easily skewed right now by how it weighs the various sources of information. It may recommend chemo regimen X based on Y and Z guidelines, but regimen Q may be better because you know those guidelines are disputed and maybe not as applicable to your patient. This will certainly get better with time, but even then will need a highly informed human to fully wield it.

Steven Reznick

At the local medical school my students attend, they are being trained to use all information resources available to them. While we hope to train doctors to perform research of the literature at the highest level, the snapshot overview of a disease process they get from many of the sites discussed above refreshes their thought processes and directs them to the more acceptable scientific data.
The basic sciences are still the backbone of your frame of reference. The experience you receive in clinical situations and the application of the basic science directed by clinical supervisors separate you from the educated patient. Yes it is great to discuss health care with highly educated and knowledgable patients and family members but in the end you still have to advise what is best for the clinical situation based on the patients needs and your education and frame of reference.
I think the author, while articulate and well meaning , needs a few years of clinical training and practice before he condemns his education as that of an old used car salesman

jonnycrocket

Thanks for taking the time to comment, Steven. I don’t disagree that basic science is the backbone. It’s precisely because it is the backbone that it needs to be taught as well and as effectively as possible. I also think we need to be training with an eye towards the future. We shouldn’t be training physicians like we have always trained them simply because we’ve always done it that way.

David Gelber MD

My patients frequently come to their appointments armed with their Internet printouts and series of questions a website has told them they should ask. This is particularly true of breast cancer patients. I take the time to address each issue that is raised and together we develop a proper treatment plan.
I agree that knowledge of the basic sciences becomes more important as i try to explain why the information my patient has gleaned from WebMD may not exactly pertain to their situation.
I think medical education needs to emphasize applying basic science to clinical medicine in ways that help our patients understand the disease process and be active participants in their treatment plan.

John C. Key MD

I find the basic sciences to be extremely important, perhaps moreso today than 30 years ago. By basic sciences I don’t mean just pre-med and anatomy, physiology, biochem but also your basic textbook med/peds, surgery, OBG and psych too. And at age 64 I am one of those docs who relies a lot on Wikipedia and Medscape and WebMD but I would suggest that it is only because of my long-ago and-far-away training in those basics that makes me able to quickly understand what I read today online and incorporate it into an accurate clinical picture,

Isn’t it really de rigueur for ALL of us as medical students to feel that we were wasting our time studying all those basics? I sure did, but now looking back over the decades I wish I’d even studied a little more.

It is only through this vast fund of knowledge that we can interact with that printout-bearing patient for the mid-level practitioner who as overlooked some nuance of the H&P or lab panels.

Good thoughts, Dr. Coleman, but there is no free lunch.

Karen Ronk

As patients, we have more time to do the online research about our own conditions than a doctor has time to think about what is wrong with us. I was misdiagnosed and through my continuing research ( and my physical therapist) , was able to steer my treatment in the right direction. I am still not better, my condition may or may not ever get better, but at least we are not wasting time ( and money) going after the wrong treatment.

The key was that my doctor was open minded and not threatened or annoyed by my diligence in trying to help myself.

jonnycrocket

Thanks for your comment Dike. I agree that the basic science education is as important, if not more so, than ever. But I think it needs to be taught with an eye toward the future. So much of medicine, education, and medical education is repeating the same things over again simply because that’s the way they’ve always been done. The physician-patient relationship is going to change in the future, but we’re training our physicians like things will always remain the same.
I really appreciate you taking the time to read and comment on the article. I think it’s an important conversation to be having.

jonnycrocket

That’s precisely my point. To not fear or revile them. But in order to do this, we need to train physicians in a way that does not illicit fear of revulsion. I disagree that we are adequately training our physicians for this paradigm shift. A more level playing field calls for transparency and effective communication. To stick with the car salesperson analogy, we need to be creating the CarMax of physicians.
An informed patient requires a different type of patient-physician relationship, but we are training for the old, not the new.